Failure to Initiate and Document Grievance Process
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for at least one resident. Multiple complaints and grievances were made on behalf of a resident with significant medical conditions, including cerebrovascular disease, COPD, and cancer of the intestines. The resident's representative reported ongoing issues with care, communication, and staff behavior to the previous Administrator and the DON through various means such as text messages, emails, and verbal communication over a period of months. These complaints included concerns about pain management, staff responsiveness, changes in the resident's condition, and the handling of care plan documentation. Despite these repeated complaints, the facility did not initiate the formal grievance process as required by its policy. The complaints were acknowledged in some cases by the DON and the previous Administrator, but there was no evidence that the grievances were documented, investigated, or resolved according to the facility's procedures. The facility's grievance log did not contain any record of the grievances made on behalf of the resident during the relevant time period. Interviews with facility leadership confirmed that the staff did not recognize or act upon these grievances as required, and the DON admitted to not understanding the grievance process due to lack of training from the previous Administrator. The facility's own policy requires that all grievances be documented, investigated, and resolved promptly, with written decisions provided to the complainant. However, the actions of the previous Administrator and the DON did not meet these requirements, as they failed to record or process the grievances received. This lack of adherence to policy resulted in the resident's grievances not being formally heard or addressed, as confirmed by record reviews and staff interviews.